Hospital Survey Template

1. Age category

45-50

51-60

61-70

71-80

81+

2. Gender

Male

Female

3. Do your family members pressurize you to take quick action on getting your health problems checked?

Yes

No

4. Is there a major difference in the workings and performance of different hospitals within your vicinity?

Yes

No

5. Is there a substantial amount of cost difference between the different hospitals available near you?

Yes

No

6. Is there a hospital in your vicinity that you prefer the most?

Yes

No

7. If Yes then please provide the name of the hospital below:

8. Do you usually visit the same hospital every time?

Yes

No

9. How satisfied are you with the level of skills and competency that the staff possess at your preferred hospital?

Very Satisfied

Somewhat Satisfied

Neutral

Somewhat dissatisfied

Very Dissatisfied

Not Sure

10. What are your views on the overall cleanliness of the hospital?

Very Satisfied

Somewhat Satisfied

Neutral

Somewhat dissatisfied

Very Dissatisfied

Not Sure

11. How satisfied are you with the helpful and friendly nature of the staff?

Very Satisfied

Somewhat Satisfied

Neutral

Somewhat dissatisfied

Very Dissatisfied

Not Sure

12. Are you happy with the performance of the hospital according to the costs that incur?

Very Satisfied

Somewhat Satisfied

Neutral

Somewhat dissatisfied

Very Dissatisfied

Not Sure

13. How do you decide on the hospital when you or someone from your family gets sick?

You usually decide

You decide based on information from your physician

You and your physician decide together

Your physician decides based on information you provide

Your physician decides

Depends on situation

Hospital Survey Template

Upgrade your package plan!

Sign In

Register

Forgot Password